<div id="contenedor" class="container">  
    <div class="row-fluid">
        <ul class="span12 breadcrumb">
            <li class="offset5"><b>Registrar Pago</b></li>
        </ul>
    </div>
    <form class="form-horizontal">     
        <div class="row-fluid">

            <div class="span5"> 
                <div class="control-group">  
                    <label class="control-label" for="input01">Fecha</label>  
                    <div class="controls">  
                        <div class="input-prepend">
                            <span class="add-on"><i class="icon-calendar"></i></span>
                            <input id="fechaRegistrarPago" type="text" class="datePicker input-small" value="21-12-2012"> 
                        </div> 
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Recibo N°</label>  
                    <div class="controls">  
                        <input type="text" class="input-large"  value="0001">  
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Tipo Costo</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div>     


                <div class="control-group">  
                    <label class="control-label" for="input01">Descripción</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

            </div> 
            <div class="span6">
                <div class="control-group">  
                    <label class="control-label" for="input01">Proveedor</label>  
                    <div class="controls">  
                        <select>
                            <option></option>
                            <option>Proveedor1</option>
                            <option>Proveedor2</option>
                            <option>Proveedor3</option>
                        </select> 
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Nit</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Teléfono</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Correo</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

            </div> 

        </div>
        <hr>
        <div class="row-fluid">

            <div class="span5"> 
                <div class="control-group">  
                    <label class="control-label" for="input01">Valor</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Retenciones</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Pagado</label>  
                    <div class="controls">  
                        <input type="text" class="input-large" >  
                    </div>  
                </div> 

            </div> 
            <div class="span6">  

                <div class="control-group">  
                    <label class="control-label" for="input01">IVA</label>  
                    <div class="controls">  
                        <input type="text" class="input-large">  
                    </div>  
                </div> 

                <div class="control-group">  
                    <label class="control-label" for="input01">Total a pagar</label>  
                    <div class="controls">  
                        <input type="text" class="input-large">  
                    </div>  
                </div> 
                <div class="control-group">  
                    <label class="control-label" for="input01">Pendiente</label>  
                    <div class="controls">  
                        <input type="text" class="input-large"  readonly="readonly">  
                    </div>  
                </div> 
            </div> 

        </div>
        <div class="row-fluid">
            <div class="form-actions">          
                <div class="span2 offset4">
                    <button type="button" class="btn btn-inverse "><i class="icon-ok-sign icon-white"></i> Guardar</button>
                </div> 
            </div>
        </div>
    </form>
</div>  
